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I Y SCA. .., APPLICATION �} i SAN JUAAQUIN COUNTY PUBLIC HEALTkE ZD ENVIRONMENTAL HEALTH D I V I 445 N SAN JOAQUIN, PHONE (209 �flDo P 0 BOX 2009, STOCKTON, CA PERMIT EXPIRES 1 YEAR FROM DA (Complete in Triplicat -��44) , wr. r.. Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein descr . application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. J a Job Address 5vt--� City Lot Size/Acre'age I Owner's Name Address Phone Contra Addre License Phon �� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Gl F." PUMP INSTALLATION ❑ >.'SYSTEM REPAIR 0_1OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Fi' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Web Casing [ mestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing Specifications FI•1 Pubtic C1 Other f-1 Delta Depth of Grout Seal Type of Grout I I# I I Irritation Approx. Depth I I Eastern I Surface Seal Installed by F1Repair Work Done J Type of Pump H.P. Stats Work Pi rte Well Destruction ❑ Weil Diameter Sealing Material i Depth Depth Filler Material & Depth TYPE OF SEPTIC_ WORK; NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I l Mo septic system permitted if public sewer is .moi available within 200 feet.)F d I Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: v"t r table depth € SEPTIC TANK. ❑ Type/Mfg Capacity VA PKG. TREATMENT PLT.❑ Distance to nearest: Well Foundation Pro pe ffCC �I. LEACHING LINE ❑ No. & Length of lines Total}l�r�t ICI UI FILTER BED Ll Distance to nearest: Well Foundation ----ENVlR 7H S 7\ AL�e , l 141 SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and F; rules and regulations of the San Joaquin,County Home owner or licensed agent's signature oenifies the following: "I certify that in the performance of the work for which this permit is issued. 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature F, certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mu ell required ins, actions. Complete drawing on reverse side. Signed Title: .9 - - -- Date: _ m F, FOR DEPARTMENT USE ONLY Application Accepted bya Date 1 Are /� Pit or Grout Inspection by Date Final Inspection by Date 5T Additional Comments: G C' Applicant - Return all copies to: San Joaquin County Public Health Services F r' ]� Environmental. Health Permit/Services � 0 � D 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95FEE AM UNT DIJE AMOUNT REMITTED CK RECEIVED BY DAT PERMIT NO. INFO FK 13-24 1AEV,I/w 5) EH 1!•26 7002 �/V/# f�a__